In recent decades there have been significant changes in the size and composition of the migrant population in the UK with people from an increasingly diverse range of countries, nationalities, and different legal immigration statuses living in the UK. In 2008-2009, 11% of the UK population was born overseas, and among the non-UK born population, 29% had arrived since 2004. The challenges for public service providers in education and health are significant, including in areas which have historically not been large-scale migrant receiving areas.
The research evidence - particularly large scale, population-based evidence - and the policy agenda in health at national level, has not kept pace with and therefore does not reflect recent demographic changes. Thus, much of the evidence on inequalities in health outcomes and barriers to health care does not sufficiently take into account factors such as country of birth, date of arrival, nationality, language and immigration status of people born overseas. For instance, in the Marmot Review of ‘health inequalities in England post-2010’ which was published earlier this year, ethnic differences in the social gradient in health gets some coverage, but there is no mention of migrants or of factors affecting their health outcomes. What this means is that government targets to reduce inequalities in health, and in cross-cutting social determinants of health such as child poverty, education, income, employment, housing quality and area deprivation, do not take migrants per se into account. For example, we know that poor housing conditions are a risk factor for respiratory and other illnesses. We also know that some categories of, particularly recent, migrants in the UK are more likely than many among the UK-born established population to live in over-crowded housing that is in poor physical condition, often in the private rented sector in deprived areas. However, we do not have sufficient evidence of measurable health outcomes for such migrants, and the impact on these of sub-standard living conditions and of other barriers to good health and to accessing good health care.
Increasing numbers of people in minority ethnic groups are now born in the UK, so health evidence based only on ethnicity may not accurately reflect the experiences and needs of members of the minority ethnic population not born in the UK. The collection of health data in primary and secondary care administrative systems, as well as in population based surveys needs to be re-thought and re-structured. At present, there continue to be gaps in hospital and primary care data recording even ethnicity. Beyond tackling these deficiencies, it is essential to move towards understanding whether, and why, migration factors - including date of arrival, immigration routes and legal status and languages spoken - interact with ethnicity and socio-demographic factors in order to identify where migrants have different needs and experience different barriers compared to minority ethnic groups.
The existing evidence, while still largely local and qualitative and focused primarily on asylum seekers and refugees, shows why understanding the health of migrants matters. It reveals that of particular concern has been the impact on the physical and mental health of asylum seekers fleeing areas of conflict, and the trauma of migration and settlement processes such as insecurity of immigration status and social isolation. There is also evidence of material circumstances that are seen to negatively affect the health of some categories of migrants – particularly, but not solely, newer migrants, failed asylum seekers and undocumented migrants. These include: low income, poor nutrition, sub-standard housing, poor health and safety practices in some industries and workplaces employing migrants; inadequate transport creating problems for accessing health services; lack of information on the availability and entitlement to health services, inadequate language support and cultural insensitivity among some health care providers. However, there is as yet limited large scale and systematic evidence of specific health outcomes arising from these factors.
Some of the barriers to good health appear to cross length of residence in the UK, thus affecting long term established residents as well as recent migrants. There is also emerging evidence that some aspects of migrants’ health may be deteriorating over time in receiving societies. There is an imperative need to find out if such evidence is valid on a larger scale for diverse categories of migrants living in differing geographical locations, and to explore other issues that might be relevant to their health and access to health care. This has significant policy and practice implications for the delivery of appropriate health services to meet population needs at local level.
One important example is provided by vulnerable migrants whose health outcomes may be particularly negative but who may be denied entitlement to health care because of uncertainties around their immigration status. This includes pregnant women and recent mothers who are failed asylum seekers or otherwise undocumented, in detention, trafficked, or those on spouse visas who are escaping domestic violence, and have no recourse to public funds. Such women are dependant on health services at this lifecycle stage, but may be refused free access to maternity and infant health services by health care providers on grounds that they are not ordinarily resident in the UK. The existing evidence on health outcomes for such women is stark. The most recent Confidential Enquiry into Maternal Deaths (2003-2005) found that black African mothers, most of whom were recent migrants, including asylum seekers and those with unclear immigration status, were more than five times more likely to die than white mothers. Late booking, no use of antenatal care at all, and lack of access to translation services were some factors identified among mothers who died.
Another recent report showed that infant mortality rates in the West Midlands are highest in areas of deprivation in which poorer migrants live. Voluntary sector organisations, such as Doctors of the World, run projects (e.g. Project: London) providing access to essential health care for migrants who do not have sufficient information about their rights to health care, or are denied access by mainstream providers both in primary and secondary care. Examples from Project: London include a pregnant woman denied antenatal care by a GP because of a lack of documentation. In 2009, Project: London registered 974 new service users who had not been able to access the health care they needed. A recent British Medical Journal report highlighted the extent of misinformation and confusion among providers around the ever-changing government regulations for ‘overseas visitors’. According to this report, most doctors want to base their decision to provide medical treatment on clinical need rather than immigration status, but are at times intimidated by the contrary advice of some overseas visitor managers in trusts.
In an earlier openDemocracy article, Zrinka Bralo vividly invoked the plight of vulnerable migrants being denied access to life saving health care, with tragic consequences. If the aim of the proposed new governance structure in health care is to move away from national, centralised systems of decision-making and control, to more accountability to patients at a local level “whatever their need or background”, then it is imperative that the circumstances and health needs of migrants are specifically taken into account in the commissioning and delivery of services.
To read a fuller version of this article in the Race Equality Foundation’s Better Health Briefings click here